Surgical Instrumentation for Gynecological Procedures

Sponsored by:
Surgical Instrumentation for
Gynecological Procedures
LEARNING OBJECTIVES:
1. Discuss common gynecological surgical procedures.
2. List five instruments unique to gynecology instrument sets.
3. Name three anatomic structures potentially damaged by faulty instrumentation.
CIS
Self-Study
Lesson Plans
(Instrument Continuing
Education-ICE)
4. Review instrument set audit procedure for quality improvement.
Surgical instrumentation designed for gynecological procedures cover a wide
range of specialties, including laparoscopic, robotic, and microscopic. This
lesson will focus on basic instruments utilized in open gynecology procedures.
Unique attributes of female anatomy has given life to Plato’s expression,
“Necessity is the mother of invention.” (circa 375 B.C.) Instrument designers,
frequently the surgeons themselves, have worked to meet the need with
an eye toward safety. Certified Instrument Specialists (CIS) continue the
tradition by maintaining and processing gynecologic instrumentation to the
highest standard.
Objective 1. Discuss common
gynecological surgical procedures.
Carla McDermott, RN, CRCST, ACE
Education Specialist,
Morton Plant Mease Healthcare
Dunedin, FL
mailbox@iahcsmm.org
Instrument Continuing Education (ICE) lessons
provide members with ongoing education in the
complex and ever-changing area of surgical instrument care and handling. These lessons are designed
for CIS technicians, but can be of value to any CRCST
technician who works with surgical instrumentation.
You can use these lessons as an in-service with
your staff, or visit www.iahcsmm.org for online
grading at a nominal fee: $5 per lesson, or
bundled packages of 6 lessons for $25 (save $5)
or 2 lessons for $50 (save $10).
Each lesson plan graded online with a passing score
of 70% or higher is worth one point (contact hour).
You can use these points toward either your recertification of CRCST (12 points) or CIS (6 points).
Mailed submissions to IAHCSMM will not be
graded and will not be granted a point value
(paper/pencil grading of the ICE Lesson Plans
is not available through IAHCSMM or Purdue
University; IAHCSMM accepts only online
subscriptions).
The CIS will utilize their knowledge
of medical terminology and anatomy
to assure the proper instruments
are prepared for specific surgical
procedures. For instance, if the surgery
schedule lists the procedure as “Bilateral
Tubal Ligation”, a phone call will be
placed for additional information. To
appropriately prepare the instrument
set and/or case cart for the procedure,
the CIS needs to know if the procedure
is being performed in the ‘post partum’,
‘interim’ or laparoscopic mode. If the
patient has very recently delivered a
baby, the procedure is ‘post partum’ and
only short instruments are required since
the uterus and fallopian tubes are still
very high in the abdomen. An ‘interim’
tubal ligation is performed six weeks or
longer past the previous pregnancy so
longer Babcocks and Kellys are required
in the instrument set. The fallopian tubes
are very deep in the pelvic area and not
accessible with shorter instruments. The
laparoscopic procedure is only done
in the ‘interim’ and requires a GYN
laparoscopic instrument set. Preparing
instrumentation for a hysterectomy
also requires the CIS to exercise their
knowledge. Information must be
included in the scheduling function
that identifies the specific approach,
abdominal versus vaginal, and open
versus laparoscopic. Likewise, if the
patient is scheduled for an endometrial
ablation, the CIS must verify the specific
surgical approach and whether a laser
will be utilized. By following through to
obtain adequate information, the CIS
helps assure a more positive experience
for the patient, surgeon and surgical
team. Preparation allows smooth
delivery of care for the patient and
decreases frustration for the team by
eliminating delays.
Objective 2. List five instruments
unique to gynecology instrument sets.
Instruments specific to gynecology
include retractors, vessel clamps, scissors
and needle holders. Retractors unique
to gynecology include the O’Connor
– O’Sullivan self-retaining ring retractor,
Balfour retractor with bladder blade
IAHCSMM
CIS Self-Study Lesson Plans
and Heaney hand-held retractor. A
crucial consideration in processing
these retractors is assuring the edges
are smooth. A burr on the blades can
cause tissue and nerve damage. The
self-retaining retractors have multiple
moving parts that must be thoroughly
inspected for cleanliness, burrs and all
removable parts. Blades, wing-nuts or
set screws assure proper function in
use. Any missing or broken part delays
the procedure and causes undue stress.
Should missing or broken pieces go
undetected until the conclusion of the
procedure, valuable time is wasted
searching for an item that was not
present as expected. Clamps designed
to grasp and occlude large blood vessels
and ligaments supporting the uterus in
the pelvis include the Heaney, Ballantine
and Rodgers. These large sturdy
clamps can be straight or curved jaws
with serrations running horizontally or
longitudinally. The strength and size is
critical in controlling blood loss. The
CIS’s inspection of this clamp must
include the ratchet strength to assure
secure closing and prevent inadvertent
opening of the clamp in use, cleanliness
and smooth operation of the jaws. A
set usually includes three of each kind
in exactly matching size and shape. This
helps optimize available space for the
surgeon’s hand and required clamps in
the surgical field. Clamps of unequal
length increase the risk of bleeding.
Scissors must be of appropriate length.
Routine sizes are needed for opening
and closing the incision and length
of 8 to 9 inches are needed to reach
structures deep in the pelvis. The
Jorgensen scissor is a curved right angle
scissor used to seperate the cervix from
the vaginal mucosa. The prudent CIS
will test the cutting edge of this scissor
with each use because of the dense,
fibrous nature of the cervix. This scissor
dulls quickly. Needle holders and forceps
must be matching in length to enable
the surgeon to repair the tissue severed
in removal of the uterus. Heaney needle
holders have curved jaws to increase
visibility of needle placement. The jaws
of the needle holders are critical in this
function. The needles used to repair
this tissue are round bodied. The jaws
are flat surfaced. Undue wear of the
serrated jaw surface will not hold the
needle securely causing it to spin in
the tissue. Bleeding results, and can
be difficult to control. Inspection is key
in providing quality instruments and a
positive patient outcome.
Objective 3. Name three anatomic
structures potentially damaged by
faulty instrumentation.
Vital structures not directly involved
in gynecological surgeries are at risk
of damage from instrumentation.
Abdominal wall tissues and nerves can
be compressed by malfunctioning or
poorly placed retractors, resulting in
increased post-operative pain. A burr
on the blade used to retract the bladder
or bowel can tear the tissue requiring
additional repair. Major blood vessels can
be damaged by clamps that are sprung
and do not hold properly. Damaged
blood vessels means increased blood
loss that may require blood transfusion
for the patient, which significantly
increases the risk of the procedure.
Objective 4. Review instrument
set audit procedure for quality
improvement.
Quality improvement is a vital function
for the CIS. Along with the routine
care and maintenance of surgical
instruments, education is required to
assure a strong knowledge base of
the instrumentation. It is difficult to
recognize when items are missing or
damaged if there is no information
describing complete and functional
use of the instruments. Maintaining a
record of preventative care provided by
a reputable instrument service company
helps determine budgeting for repair
or replacement of instrumentation.
Surgical teams appreciate knowing
the instrument sets are properly cared
for each time they are used. Processing
and sterilization do take a toll on the
instruments. Audits that reveal “use
versus presence” of instruments in the
set can guide set make-up. Removing
instruments no longer used decreases
wear and tear on the instrument and
reduces unnecessary work load of
inspection and handling. An added
plus for the surgery team is they do not
have to count instruments that will not
be used. The audit can also point out
instruments that need to be placed in
the set. Are there instruments that are
opened for a majority of cases? Placing
them in the set reduces the time and
expense of handling, packaging and
sterilizing wrapped or peel pouched
instruments. The surgery team saves
time and effort in opening an additional
item. Improving quality provides benefits
for the patient, surgeon and the facility!
Bibliography
International Association of Healthcare Central
Service Materiel Management. Central Service
Technical Manual. Sixth Edition. 2005.
Scultz, R. Inspecting Surgical Instruments, An
Illustrated Guide. 2006.
International Association of Healthcare Central
Service Materiel Management. Instrumentation
Resource Course: Identification Handling and
Processing of Surgical Instruments. 2006.
Chen, NC; Towler, MA; Moody, FP; McGregor, W.
Mechanical Performance of Surgical Needle Holders.
Journal of Emergency Medicine. 1991; 9:477
CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
Surgical Instrumentation for Gynecological Procedures
Questions (circle correct answer):
1. “Post partum” refers to the
time period immediately after
giving birth.
7. Burrs occur only on orthopedic
instruments and not considered
a problem for GYN instruments.
True
False
True
False
2. A laparoscopic tubal ligation
can be scheduled when ever
the patient chooses.
8. Wing nuts are completely
interchangeable, therefore do
not need to be counted.
True
False
True
False
3. Surgeons are often involved in
designing instruments that
meet specific needs.
9. Heaney clamps are always used
in pairs.
True
False
True
False
4. Lasers are never used in
gynecological surgery procedures.
10. Ballantine clamps are
interchangeable with Rodgers
clamps if you run short.
True
False
True
False
5. The CIS knows to provide longer
Babcocks for a “post partum”
tubal ligation.
11. Clamps of unequal length are
preferred over equal length clamps.
True
False
6. Self-retaining instruments hold the
incision open during the procedure.
True
False
13. Heaney needle holders must have
smooth jaws and inserts.
True
False
14. Tissue damage to the bladder
and bowel can occur from
faulty instruments.
True
False
15. Quality improvement is a hallmark
of the caring and competent CIS.
True
False
Sponsored by:
True
False
12. Jorgensen scissors are designed to
be slightly curved and cut only
delicate tissues.
True
False
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